World Allergy Organization

All information received on this form is confidential.
Date of application:
Name of Regional/State/Local Society hosting the conference:
Name of person completing application:
Position within the society:
Address for correspondence:

City:
State/Province:
Postal Code:
Country:
E-mail:
Telephone:
Fax:
Please rank your preference of US GLORIA Module to host at your meeting:
	Allergic Conjunctivitis
	Allergic Rhinitis
	Anaphylaxis
	Angioedema
	Chronic Rhinosinusitis and Nasal Polyposis
	Drug Allergy
	Food Allergy
	Immunotherapy
	Treatment of Severe Asthma
	Urticaria
Would you be willing to host 2 GLORIA modules at your meeting?		Yes No
Has your society hosted US GLORIA in the past?		Yes No
Date(s) of meeting:
Site/location:
Objectives/purpose of meeting:
What percentage of your anticipated attendees will fall into the following categories?
a. Allergists
b. General Practitioners
c. Pulmonologists
d. ENT's
e. Dermatologists
f. Nurses
g. Students
h. Other Health Care Professionals
	Please specify:
Scientific program topics:
Anticipated attendance number:
Website address for the meeting:
I plan to apply to the ACAAI for Category 1 CME credits:		Yes No

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